Making It Easy to Get Shot

With vaccination rates low in some areas and outbreaks of infectious diseases cropping up in numerous places, like Minnesota, Boston (including a second round in the past week) and elsewhere, public health officials need to be a bit creative in order to get people to vaccinate. Education is certainly a major need, particularly where anti-vaccine myths and misinformation are concerned. But for those who are accepting of vaccines but may be a little lazy about keeping up with the schedule, education may not be enough. Health officials need to make it easy or perhaps even offer incentives.

The Orange County, North Carolina Health Department and nurses of the Chapel Hill-Carrboro City Schools are doing just that, by offering immunization clinics and holding a contest. Between April 1 and May 31, 2011, if students bring proof of immunization, they will receive a contest entry: 1 entry for a Tdap vaccine, 1 entry for an HPV vaccine and 2 entries for a meningococcal vaccine. There will be three winners, chosen by a school administrator. One fifth grader and one middle school student will each win an iPod, and a high school student will get a laptop.

Personally, I'm not quite sure what I think about this.

It's certainly a decent way to get at least the kids interested. With the ubiquity of personal electronics, the prizes are not all that significant. Lots of people have iPods, and laptops have become relatively cheap and almost a necessity for school - if not by high school, then at least by college. So, the items themselves may not necessarily be a huge draw, but who doesn't love some free swag? Not to mention the fun of a contest.

What concerns me a little, though, are matters of undue influence and fairness.

I'm going to start with fairness. Neither the article I linked to above nor the official announcement on the Chapel Hill-Carrboro City Schools web site make any mention of those students who, for medical reasons (primarily allergies to the vaccine or one of its components), cannot receive the vaccines. To be fair, the contest should also be open to those who would be willing to get the vaccine, but have a medical reason to avoid it. I mean, it's one thing to choose to participate or not, but another to be excluded for reasons beyond your control.

There is also the potential for students to be unduly influenced to receive a vaccination, even if they are contraindicated for it. As noted on the CHCC Schools web site, a student who is older than 16 years can sign for themselves to receive the vaccine, without having a parent present. Although I mentioned before that iPods and laptops are fairly ubiquitous now, there still are families who may not be able to afford such luxuries. Given a scenario where a student is old enough to vouch for themselves, has a contraindication and cannot afford to purchase a laptop, the incentive may be enough for them to act contrary to their better interests. I assume (and certainly hope) that the health officials running the clinics will ensure the vaccine is safe for the student, but even if they do, the student may still lie, acting on a sense of invulnerability that seems so common among the young. They might not even know that they shouldn't receive the vaccine, though their parents might. In such a case, even though the risk may, in fact, be minor (and responsible health officials should have resources on hand to deal with an allergic reaction), the incentive may have the effect of getting the student to act in a manner contrary to their best interests.

Then again, I may be reading more into this than is really there. The division between appropriate incentives and what constitutes undue influence is a fine line. There really is no objective criterion by which to judge it, and it must be handled on a case by case basis. In some cases, whether a compensation is just or unduly influential can be quite obvious, but others may be a bit murkier. It can be a very hard decision to make, sometimes.

In the end, one must look at the risks and the benefits. As the school administrators state, the contest is in honor of Julia Harrison (PDF), who died of meningitis. Although an allergic reaction to one of the vaccines is possible, even that is rare (about 0.1 per 100,000 doses for meningococcal vaccine) and can be managed with epipens or other emergency anti-allergy medicines. The risks from the disease can be quite serious and much more likely. Ultimately, the effort has a noble goal with a fun and creative means of achieving that goal. Although I generally support the effort, there is still a niggling little part of my brain that bridles just a bit. Maybe it's just my sense of fair play.

What are your thoughts?